CMU Counseling Center Student Information. Legal Name: Today s Date: (Last) (First) (Middle) Preferred Name: Preferred pronouns: Date of Birth: Age:

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1 CMU Counseling Center Student Information Legal Name: Today s Date: (Last) (First) (Middle) Preferred Name: Preferred pronouns: Date of Birth: Age: Cell Phone #: Cmich Student ID #: OK to call/leave message on cell for appointment communication purposes OK to text cell for appointment reminders OK to contact by for appointment communication purposes Local Address: On-Campus Off-Campus Home Address: (Street, Res. Hall, Apt.) (Street, Apt.) (City, State & Zip) (City, State & Zip) Ok to contact local address Ok to contact home address Student Status: Gender Identity: Identify As: Other Demographic Info.: Ethnic/Racial Group: Freshman Male Straight/Heterosexual International Student American Indian/Alaska Native Sophomore Female Lesbian Transfer Student Asian/Pacific Islander Junior Transgender Gay Current Military Black/Non-Hispanic Senior Female Bisexual ROTC Hispanic/Latino Masters Student Male Other One or Both Parent(s) White/Non-Hispanic Doctoral Student Other Prefer not to answer Completed College Multi-Racial Other Prefer not to answer Prefer not to answer Emergency Contact Information: (Name) (Relationship to you) (Cell Phone #) (Daytime #) Referral Information: If referred here, by whom? Prior Counseling or Mental Health Treatment: Any counseling or psychological services? Any services from a psychiatrist? Have you received counseling from the CMU Counseling Center? Yes No Yes No Yes No Do you consider your current situation urgent, an emergency or one requiring immediate attention? Yes No CURRENT ASSESSMENT OF FUNCTIONING Y N Please check yes to all statements that are current I am considering committing suicide I am considering seriously harming myself I am considering seriously injuring another person I am experiencing intimate partner violence/domestic violence Intimate Partner Violence/Domestic Violence relationship has recently ended I believe I am being stalked Someone close to me has died I am having strange experiences such as hearing voices or seeing things that others do not I have not slept for two days or more I have been physically assaulted I have been sexually assaulted I need to make a difficult decision in the next two or three days None of the above situations applies to me; however, my situation is urgent or an emergency and I need to be seen today I can wait until the next available appointment. Let us know if you need to be seen sooner Please turn to back of page 9/5/17

2 Student availability for a counseling appointment(s) SEMESTER (Circle One): FALL SPRING SUMMER I SUMMER II Please indicate the times you are NOT available for a counseling appointment, including classes, labs, work, internships, extra-curricular activities, etc. 8:00 Monday Tuesday Wednesday Thursday Friday 9:00 10:00 11:00 12:00 1:00 2:00 3:00 4:00 Please indicate the times you are NOT available for a counseling appointment, including classes, labs, work, internships, extra-curricular activities, etc.

3 Student Concerns Name Date The following information will assist your counselor in understanding what brings you to the Counseling Center. Completing this form is VOLUNTARY. Only answer questions if you are comfortable doing so. It is okay to leave as many questions unanswered as you like. Please mark the CURRENT concerns or topics that you would like to address in counseling: traumatic experience(s) friends sexuality concerns academic concerns bullying LGBTQIA+ related concerns difficulty with study skills roommates diversity concerns time management family suicidal thoughts or feelings class attendance homesickness self-harm behavior motivational problems significant ther/partner/spouse homicidal thoughts or feelings work-related problems sleep problems frightening/unwanted thoughts major / career indecision grief/loss nightmares career information self-esteem flashbacks financial concerns health-related concerns alcohol use or abuse anxiety chronic illness substance use or abuse worry sexual assault weight concern depression harassment anorexia anger stalking bulimia loneliness intimate partner violence physical assault stress domestic violence dysfunctional family relationships childhood sexual abuse disability In order of importance, what is/are the goal(s) you have with respect to your participation in counseling? Briefly describe any previous counseling / therapy or psychiatric treatment you have received. How many sessions do you think you will need to address your current counseling concerns? MEDICAL BACKGROUND: Current state of health: Poor Okay, some problems Good Excellent List any medications you are currently taking and what they are for: In the past have you taken or been prescribed psychotropic medication (i.e. for depression, anxiety, psychiatric concerns)? Please list: Do you have any current health-related concerns? Yes No If yes, briefly describe: Do you have a disability? Yes No Prefer not to answer Do you need any accommodations to access Counseling Center services? Yes No If yes, what is the accommodation?

4 PLEASE ALL THAT APPLY Physical/Emotional Status: I have recently had problems with: I have tried to control my weight with: sleeping anxiety vomiting diet pills appetite weight loss/gain excessive exercise other mood shifts laxatives headaches not eating General: I do not handle stress well I often get extremely angry I have difficulty expressing my emotions At times, I have acted in a violent manner I am having academic problems Sometimes I hear strange voices in my head I have suffered a recent loss (death, job, pet, Sometimes I do not know where I am relationship ending) I have experienced unwanted sexual contact Alcohol Use: Other Drug Use: The following have resulted from my use of alcohol/other drugs: I use alcohol: I use other drugs recreationally traffic violation black outs never never ruined relationships disciplinary action rarely rarely fight with a friend did something I later regretted sometimes sometimes academic problems often often Relationship Status: Nature of Relationship: Support System: single partnership toxic few friends dating separated abusive many friends married widowed healthy strong support system divorced living with significant other other other Living Situation: on campus alone I am not happy with my living arrangements at school off campus with a roommate(s) with family fraternity/sorority how many? Family Background: mother living permanent home with step-parent number of older siblings father living adopted number of younger siblings parents divorced foster care number of children Nature of Family Relationships: healthy good communication chaotic my relationship with my family is not satisfactory loving emotionally abusive physically abusive I cannot talk to my family about personal issues close highly dysfunctional alcoholic in family other not sure distant Family History: counseling poor communication health concerns financial stress mental illness alcoholism/drug abuse abuse other Religious Affiliation/Spiritual Background: Employment Status: Employer: number of hours weekly: School Status: Major: Minor: Current # of credits this semester: Cumulative GPA: Are you satisfied with your: academic performance? yes no Career direction? yes no Is there anything else you would like your counselor to know?

5 Consent to Receive Counseling Services Welcome to the Counseling Center: INDIVIDUAL, GROUP AND CRISIS/EMERGENCY COUNSELING SERVICES AND ASSISTANCE The Counseling Center provides time-limited/short-term individual and group counseling for currently enrolled CMU students. CMU students who complete classes spring semester, and who are registered for classes the following fall semester, are eligible to receive counseling during the summer. Counseling services are designed to assist students with personal, career and academic concerns. To best meet the needs of as many students as possible, a limit to the type and amount of services available has been established. You and your counselor will discuss the number of counseling sessions you may require. Students who need longer term service and whose counseling needs exceed the Counseling Center s Scope of Practice (available upon request) will be referred to other more appropriate sources of assistance. Individual counseling sessions are 45 to 50 minutes in length. Same day or next day initial appointments with counselors are generally available throughout the academic year. Students with URGENT concerns will be given priority. Please inform the receptionist if your situation is urgent and you need to be seen today. The Counseling Center is open Monday - Friday, 8:00 a.m. to 5:00 p.m. when the university is open. Summer hours are Monday through Friday from 8:00 a.m. -12:00 p.m. and 1:00 p.m. 5:00 p.m. Crisis assistance is provided by phone 24 hours a day by Listening Ear ( ), National Suicide Prevention Lifeline ( ), Women s Aid Services ( ) and Community Mental Health for Central Michigan ( ). In an emergency situation dial 911. After hours, the Counseling Center counselor on call may be contacted by phoning CMU Police at Referral information is available in our reception area and on the Counseling Center s website. Counseling Groups are offered by the Counseling Center. Discuss with your counselor what groups may be helpful for you. COUNSELORS Counseling services are provided by licensed or limited licensed mental health professionals and trainees. Your counselor will provide you with a Professional Disclosure Statement to inform you about his/her training and practice. Copies of all counselor Professional Disclosure Statements are available in the reception area. At times a student seen for an initial appointment by one counselor may be referred to another counselor for scheduling reasons. If you are uncomfortable with your counselor, discuss this with him/her if possible. You may request to be seen by another counselor. Decisions to change counselors or stop counseling are respected. WAIT LIST You may be placed on a wait list following your initial appointment if all counselors schedules are filled. You will be notified as soon as an opening occurs that fits your schedule. Feel free to contact us regarding your wait list status. While on the wait list you may request a single session if you believe that you need to be seen immediately. CANCELLATIONS AND MISSED APPOINTMENTS Counseling services are in high demand. If you need to miss a counseling appointment due to illness or for any other reason, please notify the Counseling Center as soon as possible before your appointment, and AT LEAST 24 HOURS IN ADVANCE. You may be removed from your counselor s calendar if you no show for an appointment without calling to cancel in advance, or if you repeatedly cancel appointments. CONFIDENTIALITY The information you share in counseling is privileged and confidential. Counselors consult with one another as needed to assist students. A signed Consent for Release of Privileged Information Form is required to disclose to a third party any information about the counseling you have received. There are exceptions to confidentiality. If you are under 18, discuss with your counselor how this may impact some aspects of confidentiality. Your counselor is required to report disclosed information to the appropriate authorities: 1. When serious and foreseeable harm to you or others is evident; 2. When release of confidential information is required by court order or requested by you; 3. When child abuse or neglect is evident or suspected; 4. When abuse, neglect or exploitation of adults who are vulnerable due to physical or mental impairment or advanced age is evident or suspected. Some confidential client information is kept in locked Counseling Center files, stored on password protected Counseling Center computers and/or on a HIPAA compliant virtual server. No individual data or information is reported outside of the center. Computers are password protected and access limited to professional counselors and office professionals. Because , cellular and cordless phones, and fax machines are not secure means to transmit confidential information we discourage using them for this purpose. PLEASE TURN TO BACK OF PAGE COUNSELING RISKS AND BENEFITS

6 Sometimes as you change the relationships around you change. Counseling often involves talking about and expressing intense and possibly painful emotions, facing and dealing with difficult situations in the present, or recalling difficult, frightening or challenging times. Counseling may result in feeling better about oneself and others, strengthening coping skills, reaching or making progress on one s counseling goals, improving interpersonal relationships, solving problems, improved academic performance, determining a major/career direction, having a safe place to express emotions, or building on one s strengths. Discuss questions or concerns you have about the possible risks and benefits of counseling with your counselor. YOUR RIGHTS AS A CLIENT 1. The right of confidentiality, as defined on the previous page. 2. The right to ask questions and be informed about the nature of counseling and the Counseling Center's services. If you do not agree with some part of the services you are receiving, you have the right to withdraw this consent to receive services at any time. 3. The right to be treated with respect for your personal dignity, autonomy, and privacy. Counseling Center faculty and staff members strive to protect and promote the basic human dignity to which you are entitled. 4. The right not to be discriminated against because of your age, gender, race ethnicity, national origin, religion, sexual orientation, disability, or socioeconomic status. 5. The right to request a different counselor than the one assigned to you. 6. The right to terminate counseling at any time. 7. The right to a defined counseling goal mutually decided upon by you and your counselor. 8. The right to be informed, if at all possible before your scheduled appointment time, if your counselor is ill or for other reasons unable to meet with you. 9. The right to be referred to another helping professional if you desire or could benefit from long term counseling, or if your concerns go beyond our expertise or Scope of Practice. YOUR RESPONSIBILITIES AS A CLIENT 1. To inform the administrative secretary by phone AT LEAST 24 hours in advance or as soon as possible if you cannot meet your appointment time. 2. To be on time for appointments with your counselor. 3. To be honest with your counselor, to let him/her know what you like or do not like about what is happening in counseling, or if you feel counseling is not meeting your needs. 4. To be actively involved in the counseling process by stating your counseling goals, helping to determine session direction and focus, discussing issues that are important to you, using time outside of each session to work on your counseling goals, attempting to change when this is relevant, and learning how one's growth and development can continue following counseling. 5. To tell your counselor if you wish to terminate the counseling relationship or wish to request a different counselor. Please discuss any questions or concerns about your counseling or the Counseling Center with your counselor, other CMU counselors, the Counseling Center Director Dr. Ross Rapaport, or Associate Vice President for Student Affairs Mr. Tony Voisin ( ). The Counseling Center welcomes your comments and suggestions concerning the services we provide. Formal complaints about a counselor may be made to the state licensing board: Michigan Department of Licensing and Regulatory Affairs, Bureau of Health Professions, Allegation Section, PO Box 30670, Lansing, MI 48909, (517) Your signature below indicates you have read the "Welcome to the Counseling Center", "Your Rights as a Client", and Your Responsibilities as a Client statements and agree to receive counseling from the CMU Counseling Center. Student Name Date CMU is an AA/EO institution, providing equal opportunity to all persons, including minorities, females, veterans, and individuals with disabilities. CMU provides students with disabilities reasonable accommodation to participate in educational programs, activities, or services. Students with disabilities requiring accommodation to participate in class activities or services or to meet course requirements should first register with the office of Student Disability Services (120 Park Library; telephone: ; Telecommunications Device for the Deaf: ). Individuals with disabilities requiring an accommodation in order to participate in counseling should contact the Counseling Center at , to mailto:counsel@cmich.edu counsel@cmich.edu, or stop by the Counseling Center at 102 Foust Hall.

7 Please Read and Sign Counseling Appointments No Show and Cancellation Policy To cancel a scheduled counseling appointment, please call the Counseling Center at least 24 hours in advance. This will allow another student to use the appointment. Students who do not attend their first scheduled counseling appointment will be removed from their counselor s calendar. Students who do not attend a recurring counseling appointment have 48 hours to contact the Counseling Center to confirm they will attend their next scheduled counseling appointment. If the Counseling Center is not contacted in 48 hours the student will be removed from their counselor s calendar. Students who repeatedly cancel appointments with less than 24 hours notice or don t show up for counseling appointments must meet with the Counseling Center director or designee before scheduling additional regular counseling appointments. Please discuss any questions about this policy with your counselor, Counseling Center Director or Counseling Center Associate Director. I have read and understood the Counseling Center No Show and Cancellation policy. Student name Date CMU Counseling Center June 29, 2016

New Patient Intake. Boynton Health Mental Health Clinic. If you are new to the mental health clinic or have not been seen in over one year:

New Patient Intake. Boynton Health Mental Health Clinic. If you are new to the mental health clinic or have not been seen in over one year: New Patient Intake Boynton Health Mental Health Clinic Welcome to the Boynton Health Mental Health Clinic The Mental Health Clinic is open to degree-seeking University of Minnesota Twin Cities campus students